17.01.2019

Preparing the final assault

James Linney examines the fraud that is NHS England’s ‘long-term plan’

I imagine, as Theresa May announced the Tories’ ‘long-term plan’ for the national health service in Liverpool last week, that she was hoping it would give the media something positive to focus on, providing a short respite from her Brexit nightmare.

The published plan - a collaboration between the department of health and Simon Stevens’ NHS England - comes on the back of the government’s pledge of an extra £20.5 billion per annum over the next five years, equating to a funding increase for the NHS of 3.4% per year on average. No doubt this increase and the fanfare around the long-term plan are a symptom of May’s fear of a general election in the near future. She may even be holding out the hope that, when it comes, she will still be prime minister. Either way, the Tories will try to use these funding increases as evidence that they are committed to the NHS, and that in no way have they been systematically cutting its funds and demoralising its workforce since they took office in 2010.

Stevens, for his part, would like us to believe that both the plan and the extra funding derive from his hard work campaigning on behalf of the NHS. Obviously neither of these things are true and, as we will see, despite the positive headlines, the long-term plan simply represents business as usual. And for Stevens - previously CEO of a division of UnitedHealth Group (a giant US private healthcare company) - and the Tories, this business is all about the dismantling and selling off of the NHS.

James Joyce famously said of his novel Ulysses that all the enigmas and puzzles he had hidden within it would keep the professors busy for centuries arguing over its meaning. Something similar could be said of the 136-page ‘NHS long-term plan’1 and healthcare workers. However, what at first glance appears gibberish in Ulysses, further examination rewards us with deeper meaning and understanding, whereas all the usual confusing, technocratic health jargon in NHS England’s document - which superficially could be mistaken for some form of competence - on further examination reveals only negligent optimism, lies and general nonsense.

The first chapter of the document is a prime example. It is titled: ‘A new service model for the 21st century’, but despite this it contains nothing new. Instead we read the same old soundbites that health service managers have been echoing for years: namely calls for more “joined-up and integrated services”, “person-centred care”, more focus on prevention, the transfer of care to ‘the community’, etc. None of which are necessarily bad ideas in and of themselves, but they illustrate a pathological disconnect with the realities of the NHS on the ground. A decade of funding withdrawal from both health and social care has left all services in a desperate situation: most hospitals (66%) are running a deficit,2 there are massive bed and staff shortages, and people are unable to be discharged because social care has been decimated. All of which are substantial barriers to “joined-up” and “person-centred care”.

Amongst all the empty jargon of the first chapter though lies a more insidious intention: the commitment to ‘integrated care systems’ (ICSs), which we are told are “central to the delivery of the long-term plan”. They “bring together local organisations to redesign care and improve population health, creating shared leadership and action”.

In reality ICSs are simply rebranded ‘accountable care organisations’ (see my previous article3) and what they actually do is force groups of GP surgeries and hospitals to amalgamate into regional networks, mirroring US-style health maintenance organizations (HMOs), thus paving the way for regionalised economies of scale. The result is a more disjointed health service, greatly facilitating the final assault on the NHS in the shape of its capture by private health firms. As GP and author Youssef El-Gingihy writes,

Integrated care systems (already being rolled out) could ultimately become integrated care organisations with a single provider responsible for regional health and social care. There is presently nothing to stop these multi-billion-pound, 10-year contracts from being won by a private health or insurance company.

Outsourcing

The second chapter of the ‘long-term plan’ commits the NHS to greater focus on prevention of illness by aiming to reduce smoking, obesity, alcohol abuse and drug use. All very admirable goals and obviously preventing someone from getting an illness is preferable to treating them after they get ill. Yet, when we consider the realities of the NHS’s dilapidated resources and services, these commitments read like a bad joke.

To use where I work in Yorkshire as an example, over the past few years the combination of forced ‘efficiency savings’ and the opening of the door for private companies to bid for contracts has meant that our local smoking-cessation clinics, weight-loss services and alcohol and drug teams are now all run by private health firms. This has led to an absurd situation, where GP surgeries actually lose money if they prescribe medications to help people stop smoking, while the privately-run weight-loss service just gives patients three months’ access to ‘Slimming World’,4 but they no longer qualify for NHS dietetic support. These examples - by no means unique to my area - highlight the ongoing process of privatisation by stealth, whereby patients are often unaware that their care is outsourced to these companies. The Health and Social Care Act (2012) forces services to be put up for tender to “any qualified provider” and private health firms simply do what comes natural to them: offer third-rate care on the cheap.

The fun continues in the third chapter of the ‘long-term plan’, which relates to ‘quality improvement’. It is the chapter which has made most of the headlines, but contains little in the way of substantive content. It sets out what amounts to a list of very unachievable ‘ambitions’, with no real explanation as to how to achieve them. So, for example, we are told that the plan will achieve a “50% reduction in stillbirths, maternal mortality, neonatal mortality and serious brain injury by 2025”. This sounds great, but there is no explanation as to how it will come about. The “50% reduction” is a figure that has apparently been plucked out of the air because it sounds impressive. Similarly, we are told that the plan will lead to a 25% increase in cancers being diagnosed in the early stages, which apparently will lead to the saving of 55,000 lives every year. The chapter continues with further arbitrary claims about cardiovascular disease, respiratory disease and diabetes - each claim being as vague when it comes to the achievement of these aims as the others.

Now don’t get me wrong: it is admirable to have goals, but all this has to be placed in the context of the actual reality of the crisis within our GP surgeries and hospitals. A crisis that makes all the of the claims of quality improvement absurd - ambitiously absurd, you might say. Compare, for example, the fantastical claims of saving lives made with the real and evident, indescribable suffering which the more than £40 billion ‘efficiency’ cuts has caused. Cuts that a British Medical Journal study found has already led to more that 120,000 excess deaths in the UK.5 These ‘efficiency savings’ are to continue despite the pledged increase in funding - a pledge which is woefully inadequate, not even matching the historical average annual growth in spending of 3.7% and falling below the 4% extra which the Institute for Fiscal Studies estimated would be needed just to enable the NHS to provide basic services. All this means that, despite the bold claims, the current situation, where accident and emergency, cancer care and planned operation waiting times are at their worst ever levels, is only going to get worse.

And it is not just the cuts, the selling-off of NHS services to private companies, hospital closures and bed shortages that reduce this plan’s goals to fairy tales: it is also the huge staff vacancies. A recent publication by King’s Fund tells us: “Across NHS trusts there is a shortage of more than 100,000 staff … [and] this number could be more than 350,000 by 2030.”6

The NHS is haemorrhaging staff and is unable to recruit for several reasons - it is known that existing staff are overworked and victims of a decade of pay freezes, while the nursing bursary has been abolished, university fees have soared and Brexit is on the horizon (to name a few). The solutions offered in chapter 4 of the ‘long-term plan’ are beyond inadequate. They add up to offering discounted online university degrees for nurses (a terrible idea, amounting to the training of nurses through apprenticeships), cheaper labour and international recruitment: ie, the poaching of staff from poorer countries.

Moving wearily on to the fifth chapter, we are told that the digitalisation of the NHS will be a major focus of the coming 10 years and very soon the healing powers of artificial intelligence and diagnostic apps will be rapturously embraced. Thus, we are ominously informed, the plan will, “encourage a world-leading health IT industry with a supportive environment for software developers and innovators”.

Let me be clear - cutting-edge, tested and safe technology should be made available to the NHS, but, as I have previously pointed out, the current capabilities of AI technology for diagnosing illness have been hugely exaggerated and, despite secretary of state for health Matt Hancock’s full endorsement, their safety and effectiveness is entirely untested.7 The reason for this irresponsible championing of unproven technology is because, as is happening globally, tech firms see health provision, and the NHS specifically, is a market ripe for exploiting. If this tech-company gold rush is allowed, NHS privatisation will go into hyper-drive and standards of care will nose-dive.

The future

So, as we have seen, despite the positive headlines, the ‘long-term plan’ equates to little more than the continuation of the scheme to undermine the NHS. For the Tories the very modest increase in funding that they have pledged - although woefully inadequate in preventing the further disintegration of the NHS - will be useful propaganda in the event of an early general election. Meanwhile, the campaign of disguised privatisation continues.

The triggering of a general election and a Labour Party victory, with the injection of funding that would come from this, would offer some hope of arresting this process in the short term. And a reversal of the provisions of the Health and Social Care Act, agreed at the 2018 Labour national conference, would be a step in the right direction. But we must demand much more radical solutions for the NHS. Not only must it be fully funded, but it must be run by democratically elected representatives of its workers. We demand the socialisation of pharmaceutical companies, free university courses and living wages for trainees.

And, of course, we must not forget our own long-term plan - the only one that can offer an end to global health inequality: the replacement of the entire capitalist system with one based on radical, working class democracy - a society of genuine socialism.